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vv�nChe i* WasteManagemer Inc. G NERATOR'S WASTE PROFILE SHEET EB 3 614 Profile# (Please caret illy read the instructions before completing this form. Please print in ink or type) Sales# (� rvice Agreement on file? Yes ❑ Nc ❑ Classification: Class K� Class II❑ Daily Cover❑ Non Haz.❑ TSDF requested Technology requested ❑Check here if this is a Recertification ❑Check here if a Certificate of Destruction or Disposal is required GENERAL INFORMATION 1. GENERATOR NAME: S` -,• A v L �—al. _ c G�.,enerator USEPA ID: CAL- 00D I(oO� qS 2. Site Location: �- �� Billing Address: (Same: o N �-U !! `` 3. Technical Contact/Phone: 4.r - it - 0 4. Alternate Contact/Phone: ` - of Billing Contact/Phone: Fax Number: z2CD9 - Fax Number: PROPERTIES AND COMPOSITION 5. A. Process Generating Waste: PC, . 6—P, r B. Is the waste from a CERCLA or state mandated cleanup?Yes❑No Location Name: C. Is your waste a result of a clean-up action and qualifies for reduced CA BOE Tax? Yes❑ N� 6. Waste Name: `• 7. A. Is this a USEPA hazardous waste 40 CFR Part 261)? Yes❑ N B. If D001, D002, D003,D004-DO43 o any underlying hazardous constituents(U C's)apply? Yes❑ No❑ (if yes,attach UHC form) C.Does this waste contain debris(List size and type in chemical composition)? Yes❑ NoX D.Identify ALL USEPA listed and characteristic waste code numbers(D,F,K,P,U): N ei'J t- State Waste Codes: I F£I E. Does this waste contain any Class I or Class II ozone depleting substances? ❑Yes(List in chemical composition) V0 8. Physical state @ 70°F;A,Solid L quid❑ Both❑ Gas❑ B.Single LayeXr Multilayer❑ C.Free Liquid range r) to % 9. A.pH:Range to or Not applicablix B.Strong Odor ❑:describe C.Color �. Liquid Flash Point:<73°F❑ 73-99° ❑ 100-139°F❑ 140-199°F❑ >200°F Cl N.A. CHEMICAL COMPOSITION: List AL constituents(including halogenated organics and UHC s) present in any concentration and forward available analysis. Constituents Range Units Constituents Range Units TOTAL COMPOSITION MUST EQUA OR EXCEED 100% 12. OTHER: PCB's, if yes,concentration(dry weight) ppm, PCB's regulated by 40 CFR 761 ❑ Pyrophoric❑ Explosive❑ Radioactive❑ Water Reactive❑ Shock Sensitive CI Oxidizer❑ Carcinogen❑ Infectious❑ Other 13. If Benzene is present,concentration •1-- ppm. Is the waste subject to the Benzene Waste Operation NESHAP? Yes❑ No❑ Unknown❑ 14. Is the waste subject to RCRA subpart C controls? Yes❑ NA-A_Volatile organic concentration,if known ppmw. 15. If the waste is subject to the land ban nd meets the treatment standards,check here: and supply analytical results. SHIPPING INFORMATION 16. PACKAGING: Bulk Solid❑ Type/Size: Bulk Liquid ❑Type/Size Drum Type/Size S G • ' Other 17. SHIPPING FREQUENCY: Units I + Per: ❑Month ❑Qtr. ❑YearOne Time ❑Other SAMPLING INFORMATION 18. A.Sample source(drum,lagoon,Pon , ank,vat,etc.) Dato Samplod: -1 Samplor's Namo/Company: 8 e- S ro C B.Generator's Agent Supervision Sarr pling 19. ❑ No sample required(See instructions) GENERATOR'S CERTIFICATION I hereby certify that all information submitted in his and all attached documents contains true and accurate descriptions of this waste.Any sample submitted is representative as defined in 40 CFR 261 -Appendix 1 or by using an equivalent method.All relevant information regarding known or suspected hazards in the possession of the generator has been closed.I authorize CWM to obtain a sample f m any waste shipment for purposes of recertification. If this certification is made by a broker,the undersigned signs as authorized mt of the generator and has confirmed the int rmation contained in this Profile Sheet from information provided by the generator and additional information as it has determined to �__e reasc b necessary. /I r, ignature Printed(or typed)Kame and title Date If the waste profile is approved,Chemici I Waste Management,Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CWM Form 6000-DI replaces the following forms: CWM-51,CWM 6000,CWM 50-A-2,CWM 50-B,CWM 6000C AND CWM Form 6000-D. WM101